Guest Form

18+ Holiday to Wales

Your Details

First name:

Last name:

Home Tel No: Mobile:

Email:

Postal Address: Postcode:

Where do you live? How many family members regularly care for you?

Next of Kin Details

Name: Relationship:

Mobile: Email:

Postal Address: Postcode:

Home Telephone Number:

Emergency Contact Details

If next of kin are going abroad during the holiday please add a contact in the UK.

Name: Relationship:

Phone Number:

GP Details

GP Name: GP Telephone Number:

Surgery Address: Postcode:

We may need to contact your Doctor - please indicate your agreement

Guest Information

Date of Birth: Height:

Age: Weight:

Do you require a specific diet?

If yes please give details

My disabling condition is:

Are you able to bear your own weight?

Do you use a wheelchair?

Is your wheelchair?

Would you be bringing your wheelchair on holiday?

Would you need to stay in your wheelchair on a coach?

Would you require assistance with transfers out of your wheelchair?

Do you use a hoist (please provide your own slings)

Do you use a shower chair?

Do you require any other mobility aids? if YES please list below

Medical Conditions

Please indicate if you have any of the following:

Diabetes

Mobility problems

Asthma

Incontinence

Heart problems

Respiratory Problems

Nervous/Mental Health Problems

Learning Difficulties

Epilepsy If so, when was the date of your last seizure: How often are your seizures?

Allergies If yes, please provide details:

Phobias If yes, please provide details:

Anything else that may be relevant?, if so please list

I need assistance in the following areas

The services of a nurse

Medication

Eating

Washing

Dressing

Using the toilet

Transfers

Attention during the night

If YES please give details in full, especially services of nurse, as much information as possible helps us greatly.

Care Plan

Do you have a current care plan? Please either attach one with this application or send a hardcopy to the 3H office.

Medication

Please list all medication and dosage

Additional Information

What is your preferred method of communication (eg Verbal, BSL, Gesture)?

What are your hobbies/interests?

How did you find out about 3H Fund?

Preferred Travel Arrangements

How will you be travelling to the holiday venue?

I would prefer future correspondence from 3H by:

Under the data protection regulations 1998 and to comply with new regulations coming into effect from 25 May 2018, we need your consent in respect of the following, and would be grateful if you would select your agreement using the dropdowns provided:

1. All your personal data shall be kept confidentially by 3H for a time deemed necessary. 2. 3H will forward your personal data to the necessary parties who will have been made aware of their obligations to abide to all aspects of the new data regulations and particularly in respect of confidentiality and safe keeping. 3. 3H Fund may wish to publish photographs with your first name and/or short video clips which include you, in their various publications, 3H website, Facebook, Twitter and may use your details for other promotional and reporting purposes. 4. 3H Fund may wish to keep you up to date with our news and offers. If you wish to be added to our mailing list, please tick here.

Under the new regulations you have the right to request personal data held about you by us and following your request this information will be returned to you within a month.

18+ Holiday to Wales

Your Details

Next of Kin Details

Emergency Contact Details

GP Details

Guest Information

Medical Conditions

I need assistance in the following areas

Care Plan

Medication

Additional Information

Preferred Travel Arrangements

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